Method device and system for monitoring lung ventilation

ABSTRACT

A method of monitoring lung ventilation of a subject is disclosed. The method comprises recording signals from a plurality of sensing location on the chest of the subject, at least a portion of the signals being indicative of a local motion of the chest at a respective sensing location. The method further comprises operating a data processing system to analyze the signals such as to determine a status of the ventilation, thereby to monitor the lung ventilation of the subject.

CROSS REFERENCE TO OTHER APPLICATIONS

This application is a continuation of U.S. patent application Ser. No.12/162,791, filed Jul. 31, 2008, now U.S. Pat. No. 8,226,571, which is anational phase application of PCT Patent Application PCT/IL2007/000124,filed Jan. 31, 2007, which claims priority from U.S. Provisional PatentApplication 60/763,380, filed Jan. 31, 2006.

FIELD AND BACKGROUND OF THE INVENTION

The present invention relates to lung ventilation and, moreparticularly, to a method device and system suitable for monitoring lungventilation.

In the medical treatment of patients requiring breathing assistance, itis common to insert an endotracheal or nasotracheal tube into thetrachea of the patient, by way of the mouth, nose or any othersurgically created opening. One end of the tube is connected to aventilator which periodically forces air into the lungs through thetube. In big children and adult patients the inner end of the tube istypically provided with an inflatable cuff which is inflated byconventional means subsequently to the insertion of the tube into thetrachea. In small children and neonates there is no cuff and it isimpossible to fix the inner end.

It is recognized that the position of the tube within the trachea is ofutmost importance because such tithes are necessary to ensure that apatient's lungs receive oxygen, and any misplacement of the tube bothduring the intubation or during ventilation, can have dire consequences.Once inserted into the trachea, the naso- or oral endotracheal tube mustoffer continues and substantially obstacle-free ventilation path to bothlungs. If inserted too deeply, the tracheal tube may enter one of thetwo main stem bronchi (typically the right) and direct air flow to andfrom only one of the lungs. Asymmetric or one lung ventilation alsooccurs clue to displacement of the tube after changes in posture orfollowing repositioning of the tube and development of heavy secretions(foreign body) in the big airways. Asymmetric or one lung ventilationmay lead to the development of respiratory insufficiency and subsequenthypoxia, hypercapnia and acidosis. Furthermore, one lung inflation cancause hyperinflation of one side leading to pneumothorax at that side,and simultaneously can create atelectasis at the other side, leading toother complications as lobar pneumonia, and the like. Conversely,displacement of the tube to or above the vocal cords may result ininsufficient ventilation and/or damage to the vocal cord. Additionalcomplications which may occur during ventilation are pulmonarybarotraumas, such as pulmonary interstitial emphysema, pneumothorax andpneumomediastinum. Such barotraumas are caused by lung disease and/orhigh air pressure in the lungs which results in rupture of alveolarstructures and lung tissue. In pneumothorax, air is present in thepleural cavity, and in pneumomediastinum air is present in themediastinum.

Another complication which may occur during ventilation is deteriorationin the gas supply, due to, e.g., malfunction of the mechanicalventilator, partial detachment of ventilator circuit, partialobstruction in the endotracheal tube by secretions, fluids accumulation,torsion, kink, and the like.

The above problems are aggravated when ventilation is performed topremature infants and patients suffering from severe parenchymal lungdiseases such as respiratory distress syndrome (hyaline membrane diseaseor adult RDS), bacterial pneumonia, pneumonitis, viral pneumonia,meconium aspiration syndrome, and other.

Of particular challenge is the ventilation of neonate and prematureinfants, because the endotracheal tube is extremely small and any smalldisplacement (within millimeters) can result in inappropriateventilation. The endotracheal tube used for newborns is not anchored atthe distal end using an inflatable cuff, and movement of the newborn andextension or flexion of the neck may displace the tube from theappropriate position. Serious life threatening complications can resultfrom inappropriate ventilation. Pulmonary air leak, such asPneumothorax, pneumomediastinum, pneumopericardium and pulmonaryinterstitial emphysema, may develop as a complication during mechanicalventilation in premature infants from excessive pressure ventilation,but may also develop spontaneously. A most dangerous complication ispartial or full detachment of the endotracheal tube with ineffectiveventilation. The associated hypoxia and hemodynamic changes induced areespecially dangerous for the vulnerable premature newborn infant and canlead to intracranial (intraventricular) hemorrhage and to thedevelopment of severe irreversible neurological sequelae as a result ofbrain damage.

Over the years, several attempts have been made to devise techniqueswhich prevent or minimize problems associated with inappropriatemechanical ventilation. These include, auscultation, air flowmonitoring, end tidal carbon dioxide monitoring, transcutaneousmonitoring of oxygen or carbon dioxide, pulse oxymetry, heart rate,respiratory rate, invasive and non-invasive blood pressure monitoringand periodic blood gas analysis, along with tight physical supervisionof the staff.

For example, U.S. Pat. No. 4,296,757 discloses a respiratory monitorwhich includes a detector for detecting the expansion of the chest ofthe person and an alarm circuit coupled to the detector for producing analarm signal if the detector does not detect expansion of the chest fora predetermined period of time.

U.S. Pat. No. 7,036,501 discloses apparatus for monitoring the carbondioxide of a patient's breath. An airway is inserted into the throat,such that a proximal end of the airway is placed at the mouth and adistal end extends through the throat to the vicinity of the larynx. Theairway includes a nipple connected to a suction device that canintermittently aspirate the throat of the patient and clears mucus tomaintain the airway open for breathing. A conduit is connected to acarbon dioxide monitor that monitors the content of the exhaled breathof the patient at the end of the respiratory cycle.

U.S. Pat. No. 3,942,513 discloses a sensor which detects respiratoryactivity and converts the activity to electrical signals to feed anapnea monitor. Once respiratory distress problems are detected, theapnea monitor transmits signals indicative of apnea episodes to an alarmunit. U.S. Pat. No. 6,168,568 discloses a system which includes aplurality of sensors placed around the respiratory system of a patientand a breath analyzer. The sensor measure breath related activity andproduce breath sound data, and the analyzer matches the data to breathsound templates, were each of the templates parameterizes one type ofbreath sound. The analyzer thus determines the presence of regularand/or adventitious breath only when the sound data matches one or moreof the sound templates.

Additional references of relevance include: U.S. Pat. Nos. 4,494,553,5,775,322, 5,785,051, 5,957,861, 5,996,582, 6,064,910, 6,139,505,6,261,238, 6,287,264, 6,315,739, 6,349,720, 6,423,013, 6,494,829,6,584,974, 6,651,665, 6,701,918, 6,705,319, 6,715,491, 6,723,055,6,765,489, 6,820,614, 6,837,241, 6,918,878, 7,094,206, U.S. PatentApplication Nos. 20030139679, 20040267149, 20050192508, European PatentApplication No. EP00956822, and Japanese Patent Application Nos.JP2002190372 and JP2004033254.

Traditional monitoring techniques, however, suffer from manylimitations, including non-automated monitoring which requires tightphysical supervision of the medical staff, frequent false alarms events,slow speed of detection, low sensitivity, particularly with thin tubes,low specificity and low sensitivity, particularly to the detection ofpneumothorax or other complications associated with asymmetricventilation.

There is thus a widely recognized need for, and it would be highlyadvantageous to have a method device and system suitable for monitoringlung ventilation, devoid of the above limitations.

SUMMARY OF THE INVENTION

According to one aspect of the present invention there is provided amethod of monitoring lung ventilation of a subject. The methodcomprises: recording signals from a plurality of sensing locations onthe chest of the subject, at least a portion of the signals beingindicative of a local motion of the chest at a respective sensinglocation, and operating a data processing system to analyze the signalssuch as to determine a status of the ventilation, thereby monitoring thelung ventilation of the subject.

According to further features in preferred embodiments of the inventiondescribed below, the signals which are indicative of the local motioncomprise local acceleration signals.

According to still further features in the described preferredembodiments the signals which are indicative of the local motioncomprise at least one type of signal selected from the group consistingof local linear acceleration signals, local angular accelerationsignals, local linear velocity signals, local angular velocity signals,local displacement signals and rotation signals.

According to another aspect of the present invention there is provided amethod of monitoring lung ventilation of a subject. The methodcomprises: recording local acceleration signals from at least onesensing location on the chest of the subject, and operating a dataprocessing system configured to analyze the signals such as to determinea status of the ventilation, thereby monitoring the lung ventilation ofthe subject.

According to still further features in the described preferredembodiments the method further comprises recording tracking signals fromat least one position tracking element and analyzing the trackingsignals for determining the position of the distal end.

According to still further features in the described preferredembodiments the method further comprises determining a referencebaseline for at least one sensing location.

According to still further features in the described preferredembodiments the method further comprises generating, a sensible alertwhen the signals deviate from the subject-specific baseline.

According to still further features in the described preferredembodiments the method further comprises further comprises recording ECGsignals from at least one ECG sensing location on the chest anddisplaying the ECG signals on an ECG display device.

According to still further features in the described preferredembodiments the method further comprises recording from at least oneadditional sensing location being on an organ other than the chest.

According to yet another aspect of the present invention there isprovided a system for monitoring lung ventilation of a subject. Thesystem comprises: a plurality of motion sensors, respectivelyconnectable to a plurality of sensing locations on the chest of thesubject, each motion sensor being operable to sense a local motion ofthe chest at a respective sensing location. The system further comprisesa data processing system, configured to receive and record signals fromthe motion sensors, and being supplemented with a mathematical algorithmfor analyzing the signals such as to determine a status of theventilation.

According to further features in preferred embodiments of the inventiondescribed below, the motion sensors comprise at least one accelerationsensor.

According to still another aspect of the present invention there isprovided a system for monitoring lung ventilation of a subject. Thesystem comprises: at least one acceleration sensor being connectable toat least one sensing location on the chest of the subject and operableto sense a local acceleration of the chest at the at least one sensinglocation. The system further comprises a data processing system,configured to receive and record signals from the acceleration sensors,and being supplemented with a mathematical algorithm for analyzing thesignals such as to determine a status of the ventilation.

According to further features in preferred embodiments of the inventiondescribed below, the system further comprises an endotracheal tubedevice.

According to still further features in the described preferredembodiments the endotracheal tube device comprises an endotracheal tubeand an endotracheal position tracking element mounted on a distal end ofthe endotracheal tube.

According to still further features in the described preferredembodiments the system further comprises a plurality of externalposition tracking elements configured to communicate with theendotracheal position tracking element, wherein at least one of theendotracheal and the external position tracking elements is operable totransmit tracking signals to the data processing system, and wherein thedata processing system is configured to receive and analyze the trackingsignals so as to determine the position of the distal end.

According to still further features in the described preferredembodiments the endotracheal position tracking element is anelectromagnetic endotracheal position tracking element.

According to still further features in the described preferredembodiments at least a few of the plurality of external positiontracking elements are encapsulated in or mounted on patches connectableto the chest.

According to still further features in the described preferredembodiments each motion sensor of the plurality of motion sensors isencapsulated in or mounted on an attachable patch, together with oneexternal position tracking element of the plurality of external positiontracking elements.

According to still further features in the described preferredembodiments each motion sensor of the plurality of motion sensors isencapsulated in or mounted on an attachable patch.

According to still further features in the described preferredembodiments the attachable patch further encapsulates an ECG electrode.

According to still further features in the described preferredembodiments the attachable patch further encapsulates at least onearrangement of electrodes being in communication with the dataprocessing system and configured for sensing at least one electricalproperty of tissue across the patch. According to still further featuresin the described preferred embodiments the motion sensors comprise atleast one sensor selected from the group consisting of a linearacceleration sensor, an angular acceleration sensor, a linear velocitysensor, an angular velocity sensor, a displacement sensor and a rotationsensor.

According to still further features in the described preferredembodiments the system further comprises a display device for displayingthe ventilation status.

According to still further features in the described preferredembodiments system further comprises a communication unit operable totransmit data pertaining the ventilation status to a remote location.

According to still further features in the described preferredembodiments the further comprises an alert device being in communicationwith the data processing system and operable to generate a sensiblealert, wherein the data processing system is configured for signalingthe alarm device to generate the sensible alert according to at leastone predetermined criterion.

According to still further features in the described preferredembodiments wherein the plurality of sensing locations on the chest,comprises a left location at a left side of the chest, and a rightlocation at a right side of the chest.

According to still further features in the described preferredembodiments the plurality of sensing locations further comprises anepigastric location at the epigastrium of the subject.

According to still further features in the described preferredembodiments the system further comprises at least one additional sensorconnectable to at least one additional sensing location being on anorgan other than the chest. According to still further features in thedescribed preferred embodiments wherein the at least one additionalsensing location comprises a back sensing location.

According to still further features in the described preferredembodiments the analysis of the signals comprises comparing signalsreceived from the left location to signals received from the rightlocation, so as to determine ventilation symmetry. According to stillfurther features in the described preferred embodiments the methodfurther comprises generating a sensible alert if the symmetry ofventilation is changed.

According to still further features in the described preferredembodiments the system further comprises an alert device being incommunication with the data processing system and operable to generate asensible alert, wherein the data processing system is configured forsignaling the alarm device to generate the sensible alert if thesymmetry of ventilation is changed.

According to still further features in the described preferredembodiments the analysis of the signals comprises calculating at leastone ventilation index characterizing the status of the ventilation.

According to still further features in the described preferredembodiments the at least one ventilation index comprises at least onelocal ventilation index characterizing the status of the ventilation forat least one sensing location.

According to still further features in the described preferredembodiments the at least one ventilation index comprises a tidal motionindex.

According to still further features in the described preferredembodiments the at least one ventilation index comprises a maximalinflation rate index.

According to still further features in the described preferredembodiments the at least one ventilation index comprises a maximalexpiratory rate index.

According to still further features in the described preferredembodiments the at least one ventilation index comprises maximalacceleration or deceleration. According to still further features in thedescribed preferred embodiments the at least one ventilation indexcomprises angular acceleration.

According to still further features in the described preferredembodiments the at least one ventilation index comprises angularvelocity.

According to still further features in the described preferredembodiments the at least one ventilation index comprises a right to leftmotion index.

According to still further features in the described preferredembodiments the at least one ventilation index comprises a transferfunction cutoff frequency.

According to still further features in the described preferredembodiments the analysis of the signals comprises calculating at leastone ventilation index characterizing the status of the ventilation.

According to still further features in the described preferredembodiments the at least one ventilation index comprises at least oneindex selected from the group consisting of a right to left flow index,an epigastric leak motion index and an epigastric leak flow index.According to still further features in the described preferredembodiments the at least one ventilation index comprises at least oneindex selected from the group consisting of a right to left flow index,an epigastric leak motion index, an epigastric leak flow index

According to still further features in the described preferredembodiments the at least one ventilation index comprises at least oneindex selected from the group consisting of a relative position of theendotracheal tube, and a displacement of the distal end. According tostill further features in the described preferred embodiments thesignals comprise at least one low-frequency component, the low-frequencycomponent being compatible with a frequency of the ventilation or anharmonic thereof.

According to still further features in the described preferredembodiments the signals further comprise at least one high-frequencycomponent, the high-frequency component being substantially higher thanthe ventilation frequency.

According to an additional aspect of the present invention there isprovided an endotracheal tube device, comprises an endotracheal tube andan electromagnetic endotracheal position tracking element mounted on adistal end of the endotracheal tube. According to yet an additionalaspect of the present invention there is provided an endotracheal tubesystem. The endotracheal tube system comprises: an endotracheal tubehaving a proximal end and a distal end; an electromagnetic endotrachealposition tracking element mounted on the distal end; and a plurality ofexternal electromagnetic position tracking elements configured toelectromagnetically communicate with the endotracheal position trackingelement. The system further comprises a data processing system.According to further features in preferred embodiments of the inventiondescribed below, at least one of the endotracheal and the externalposition tracking elements is operable to transmit tracking signals tothe data processing system. The data processing system is configured toreceive and analyze the tracking signals so as to determine the positionof the distal end.

According to still further features in the described preferredembodiments the electromagnetic endotracheal position tracking elementcomprises an electromagnetic coil.

According to still further features in the described preferredembodiments at least a few of the plurality of external positiontracking elements are encapsulated in or mounted on patches connectableto a chest of a subject.

The present invention successfully addresses the shortcomings of thepresently known configurations by providing a method, system and device,enjoying properties far exceeding the prior art.

Unless otherwise defined, all technical and scientific terms used hereinhave the same meaning as commonly understood by one of ordinary skill inthe art to which this invention belongs. Although methods and materialssimilar or equivalent to those described herein can be used in thepractice or testing of the present invention, suitable methods andmaterials are described below. In case of conflict, the patentspecification, including definitions, will control. In addition, thematerials, methods, and examples are illustrative only and not intendedto be limiting.

Implementation of the method and system of the present inventioninvolves performing or completing selected tasks or steps manually,automatically, or a combination thereof. Moreover, according to actualinstrumentation and equipment of preferred embodiments of the method andsystem of the present invention, several selected steps could beimplemented by hardware or by software on any operating system of anyfirmware or a combination thereof. For example, as hardware, selectedsteps of the invention could be implemented as a chip or a circuit. Assoftware, selected steps of the invention could be implemented as aplurality of software instructions being executed by a computer usingany suitable operating system. In any case, selected steps of the methodand system of the invention could be described as being performed by adata processor, such as a computing platform for executing a pluralityof instructions.

BRIEF DESCRIPTION OF THE DRAWINGS

The invention is herein described, by way of example only, withreference to the accompanying drawings. With specific reference now tothe drawings in detail, it is stressed that the particulars shown are byway of example and for purposes of illustrative discussion of thepreferred embodiments of the present invention only, and are presentedin the cause of providing what is believed to be the most useful andreadily understood description of the principles and conceptual aspectsof the invention. In this regard, no attempt is made to show structuraldetails of the invention in more detail than is necessary for afundamental understanding of the invention, the description taken withthe drawings making apparent to those skilled in the art how the severalforms of the invention may be embodied in practice.

In the drawings:

FIG. 1 is a flowchart diagram of a method suitable for monitoring lungventilation of a subject, according to various exemplary embodiments ofthe present invention;

FIG. 2 a is a schematic illustration of a system for monitoring lungventilation of a subject, according to various exemplary embodiments ofthe present invention;

FIG. 2 b is a schematic illustration of a patch which encapsulates amotion sensor used in the system of FIG. 2 a, according to variousexemplary embodiments of the present invention;

FIG. 3 is a schematic illustration of data processing system, accordingto various exemplary embodiments of the present invention;

FIG. 4 a is a simplified scheme of a ventilated lung model, according tovarious exemplary embodiments of the present invention;

FIG. 4 b shows a spectral analysis of high frequency ventilation,performed according to a preferred embodiment of the present invention;

FIG. 5 is a schematic illustration of an experimental setup used inexperiments performed, according to various exemplary embodiments of thepresent invention; FIGS. 6 a, 6 b and 6 c show examples of the responseto reductions in the inspiratory pressure by 66%, 33%, and 11%,respectively;

FIGS. 7 a, 7 b, 7 c and 7 d show elapsed times from initial change inpressure until a 66%, 33%, 20% and 11% decrease in the ventilationpressure was detected by the various sensors;

FIG. 8 shows examples of response to right lung ventilation;

FIGS. 9 a-b show elapsed times until changes induced by placement of theendotracheal tube into the right main bronchus (FIG. 9 a) and theesophagus (FIG. 9 b) were observed;

FIG. 10 show raw data as a function of time which demonstrate thesensitivity of the system of the present embodiments to a graduallyinduced pneumothorax; and

FIG. 11 is a flowchart diagram exemplifying a procedure for utilizingthe method and/or system of various embodiments of the presentinvention.

DESCRIPTION OF THE PREFERRED EMBODIMENTS

The present embodiments comprise a method, device and system which canbe used in lung ventilation procedures. Specifically, the presentembodiments can be used to monitor the ventilation status and/or thelocation of an endotracheal tube during lung ventilation assistance. Thepresent embodiments can be utilized for assessing the effectiveness ofany type of ventilation assistance and can also be utilized forspontaneously breading subjects.

The principles and operation of method, device and system according tothe present embodiments may be better understood with reference to thedrawings and accompanying descriptions.

Before explaining at least one embodiment of the invention in detail, itis to be understood that the invention is not limited in its applicationto the details of construction and the arrangement of the components setforth in the following description or illustrated in the drawings. Theinvention is capable of other embodiments or of being practiced orcarried out in various ways. Also, it is to be understood that thephraseology and terminology employed herein is for the purpose ofdescription and should not be regarded as limiting.

The method, device and system according to embodiments of the inventionare typically used in mammals. The mammals can be humans or animals.Examples of such mammals include humans, including adults, children,toddlers and infants (premature or full term), and animals, include,without limitation, rabbits, mice, dogs, cats, etc. As will be explainedin further detail below, embodiments of the invention are particularlywell suited for use with small mammals. Small mammals typically have atrachea of less than a few millimeters in diameter. Small mammalstypically have a weight less than about 5 Kg (e.g., about 3 Kg or less).Examples of small mammals include neonates, premature infants, rabbits,mice, puppies, kittens, rats, etc.

As used herein “about” refers to ±10%.

Yet, while the embodiments below are described with a particularemphasis to the ventilation of neonates, it is to be understood thatmore detailed reference to neonates is not to be interpreted as limitingthe scope of the invention in any way.

Referring now to the drawings, FIG. 1 is a flowchart diagram of a methodsuitable for monitoring lung ventilation of a subject, according tovarious exemplary embodiments of the present invention. It is to beunderstood that, unless otherwise defined, the method steps describedhereinbelow can be executed either contemporaneously or sequentially inmany combinations or orders of execution. Specifically, the ordering ofthe flowchart diagrams is not to be considered as limiting. For example,two or more method steps, appearing in the following description or inthe flowchart diagrams in a particular order, can be executed in adifferent order (e.g., a reverse order) or substantiallycontemporaneously. Additionally, several method steps can be repeatedone or more times, or they can be executed continuously. Further,several method steps described below are optional and may not beexecuted. The method begins at step 10 and, optionally and preferablycontinues to step 11 which is a calibration step as further detailedhereinunder. The method continues to step 12 in which signals arerecorded from one or more sensing locations on the chest of the subject.The signals, or at least a portion thereof, are preferably indicative ofthe motion of the chest at the respective sensing location. It was foundby the present Inventors that such signals are also indicative of lungventilation.

As used herein “local motion” refers to the motion of a particular areaon the chest of the subject. For example, when the signals aretransmitted by a motion sensor attached to a sensing location on thechest of the subject, the local motion refers to the motion of thetissue at sensing location together with the sensor being attachedthereto. The size of particular area to which the term local motion isattributed is preferably, but not obligatorily, less than 3.5 cm², morepreferably less then 3.14 cm², even more preferably less than 1 cm².

The signals can indicate any kinematical quantity of the local motion,including displacement, velocity and/or acceleration. More specifically,the signals can indicate linear acceleration, angular acceleration,linear velocity, angular velocity, linear displacement, rotation and/ororientation.

In various exemplary embodiments of the invention the signals areacceleration signals. The signals are preferably received from sensorsattached to two or more sensing locations on the chest. For example,signals can be transmitted from a left location at a left side of thechest, and a right location at the right side of the chest. Preferably,signals are transmitted from the upper left side of the chest and theright upper side of the chest. The left and right locations,particularly at the upper left and upper right sides of the chest areparticularly useful for determining the symmetry of the ventilation, asfurther detailed hereinunder.

According to a preferred embodiment of the present invention signals arealso received from an epigastric location at the epigastrium of thesubject. This embodiment is advantageous because it facilitates thedetection of air leak to the esophagus (stomach) and also allowsdifferentiating between assisted ventilation and spontaneous voluntaryventilation. Also contemplated, is one or more additional sensinglocations, such as, but not limited to, on the spinal bones at the backof the subject or other fixed location. Signals received from suchadditional locations facilitate correction for body motions. More thanthree sensing locations or other sensing locations are not excluded fromthe scope of the present invention.

The method continues to step 13 in which the signals are analyzed by adata processing system so as to determine a status of the ventilation,e.g., by determining volume changes of the chest using motion data. Manyanalyses procedures are contemplated, include, without limitation, thecomparison between signals originated from different sensing locations,e.g., to determine ventilation symmetry, the calculation of one or moreindices characterizing the status of ventilation and the like. Severaltypes of analyses according to various exemplary embodiments of thepresent invention are provided hereinunder. According to a preferredembodiment of the present invention the method continues to step 14 inwhich signals pertaining to the position of the endotracheal tube withinthe trachea of the subject are recorded and analyzed for determining thelocation of distal end. Step 14 can be executed subsequent to, prior to,contemporaneously with or intermittently with any of steps 12 and 13.Typically, the signals of step 14 are received from one or more positiontracking elements. For Example, several external position trackingelements can communicate with an endotracheal position tracking elementmounted on the distal end of the endotracheal tube. The endotrachealelements and/or the external elements can transmit tracking signalswhich can be then analyzed so as to determine the position of the distalend, for example, by triangulation of the signals. A preferredconfiguration for facilitating the determination of the endotrachealtube position is provided hereinunder.

The method can optionally proceed to step 15 in which ECG signals arerecorded and displayed on an ECG display device. Step 15 can be executedsubsequent to, prior to, contemporaneously with or intermittently withany of steps 12-14. The ECG signals can be recorded separate ECG sensinglocations on the chest, or, more preferably, from the same sensinglocations at which the motion signals are sensed. In various exemplaryembodiments of the invention an ECG electrode is encapsulated togetherwith a motion sensor in a patch which is attached to a sensing locationon the chest. Thus, in this embodiment, the ECG sensing locationcoincides with the motion sensing location.

According to a preferred embodiment of the present invention the methodcontinues to step 16 in which an electrical property (e.g., conductance,impedance) of the tissue contacting the patch is measured so as tomonitor the connectivity between the patch and the tissue. When theelectrical property deviates from a predetermined threshold range or asubject-specific baseline acquired, e.g., during sensor attachment, themethod identifies a detachment of the patch from the tissue. Theoperator can then reconnect or replace the patch. The calibration (step11) according to the present embodiments is a multi-step procedure whichcan comprise any of steps 12-16 described above. Thus, selected steps ofthe method can be executed a first time for calibration purposes and oneor several additional times for monitoring. Preferably, the calibrationsteps are executed after ensuring (e.g., by acoustic means) that thesubject is properly ventilated. In various exemplary embodiments of theinvention, the calibration includes at least the execution of step 12and 13. In these embodiments, the analysis of the signals preferablycomprises the calculation of one or more indices characterizing thestatus of ventilation. These indices can be presented to the operator,e.g., the physician or other medical staff members, which can then usethe indices to define a baseline for further measurements. Thus, thephysician can verify that the subject is properly ventilated, and theindices obtained during proper ventilation condition can be defined asthe baseline indices.

Additionally, the calibration can comprise the determination of theendotracheal tube position in the trachea (step 14). Thus, once thephysician verifies that the endotracheal tube is properly positioned inthe trachea, step 14 is preferably executed, and the measured position(as determined, e.g., using the tracking signals) is used for definingthe baseline position of the subject. When the calibration comprises therecording of ECG signals (step 15), the recorded signals can also beused for defining an ECG baseline for the subject. The calibration canalso comprise the execution of step 16 so as to ensure that the baselinevalues are acquired during proper connectivity between the patch and thetissue.

Calibration step 11 preferably further comprises the determination ofallowed variations from the acquired baselines, such that any deviationbeyond the allowed variations is considered as a significant change inthe ventilation status. Thus, according to the presently preferredembodiment of the invention, each index is associated with one or morethresholds which define the allowed variations for the particular index.The thresholds can be used as alert criteria during ventilation. Thethresholds can alternatively be predetermined (e.g., about ±10% or lessfrom baseline value), or the method can provided suggested thresholds tobe selected and/or altered by the operator.

Once calibration step 11 is completed, the medical staff can initiatethe automatic execution of selected steps so as to automatically monitorthe ventilation of the subject.

Optionally and preferably, the method continues to step 17 in which asensible alert (e.g., audio alert or visual alert) according to apredetermined criterion or a predetermined set of criteria. For example,the alert can be generated when the calculated indices deviate from theallowed variations defined during calibration step 11. Alternatively, analert can be generated whenever the calculated indices deviate (say, bymore than 10%, or, more preferably, by more than a few percents) fromthe baseline. A sensible alert can also be generated upon detachment ofthe patch. Preferred alert criteria are provided hereinunder.

The method, optionally and preferably continues to step 18 in which datais archived for future analysis or comparison with future measurements.The archived data preferably comprises post-processed data (e.g., thecalculated indices) and not raw data so as to save on storage volume.Archiving can be executed at predetermined time intervals. Thepredetermined time intervals are preferably selected so as not to delaythe detection of deterioration on the one hand and to reduce falsealarms on the other hand. A preferred time interval between successivearchiving extends over period of several (2-10) ventilation cycles. Theduration of a typical ventilation cycle is from about 2 second inneonate and about 6 seconds in adults, during regular (CMV) ventilation,and is about 0.1 seconds during high frequency ventilation. Thus, thepreferred time interval between successive archiving is from about 5seconds to about 30 seconds.

In various exemplary embodiments of the invention steps 12-13, andoptionally also steps 14-16 are executed continuously throughout theventilation procedure of the subject so as to allow continuousmonitoring of the ventilation and optionally heart function.Additionally, the calibration (step 11) can be repeated at predeterminedtime intervals or following an event, such as, but not limited to,repositioning of the endotracheal tube, patch replacement, subjectmovement or change in posture, environmental changes at the vicinity ofthe subject and the like. The method ends at step 19.

Before providing a further detailed description of the presentembodiments, as delineated hereinabove and in accordance with thepresent invention, attention will be given to the advantages andpotential applications offered thereby.

The present embodiments can be employed in neonatal intensive care unitsfor ventilating neonates. Neonates are prone to develop complicationsrelating to lung diseases and inadequate ventilation, which may befollowed by further acute complications, e.g., pneumothorax andintracranial bleeding. Premature newborn infants oftentimes requiremechanical ventilation, and the probability to develop complicationsincreases during prolonged ventilation periods, it is recognized thatdeterioration in ventilation may hazard the future quality of life ofthe ventilated neonate. Since the endotracheal tube for neonates istypically cuff-less, it may be easily displaced from the trachea due tomotion and changes in posture. Such displacement can lead to severehypoxia, hypercapnia and acidosis. The narrow tubes used in neonatesmake the mechanical ventilation machine insensitive to changes in theresistance to flow in the tracheal tree. Mechanical ventilation machinestherefore do not provide early detection of endotracheal tubedisplacement, and may even fail to detect deterioration in ventilation.As is demonstrated in the Examples section that follows, the presentembodiments can detect ventilation complications in small mammals withinseconds and substantially before the vital signs deteriorate. Thus, themethod, device and system of the present embodiments can provide tightmonitoring for ventilated neonates and premature newborns hencesignificantly reduce the risk of complications.

The present embodiments are also useful for monitoring the status ofhigh frequency ventilation in adults as well as neonates, where breathsounds interference complicates the monitoring via traditional acousticmeans. Since the technique of the present invention is primarily basedon the chest motion, no acoustic interference occurs. Thus, the method,device and system of the present embodiments can be employed to provideventilation monitoring during high frequency ventilation in adult andpediatric intensive care units, emergency rooms, ambulances, medicaltransport teams, operation rooms and the like.

An advantageous feature of the present embodiments is that themonitoring can be based on indices which characterize the ventilationstatus. As demonstrated in the Examples section that follows, there aremany indices which can be monitored according to the presentembodiments, but cannot be monitored by the physician. Morespecifically, the physician is limited to acoustic monitoring of breathsounds and visual assessment of the general ventilation condition, whilethe present embodiments are suitable for monitoring the mechanics oflung ventilation. The frequency of the ventilation is far below thebreath sound. Typical stethoscope delivers sounds at frequencies fromabout 20 Hz to 2000 Hz, and neither the stethoscope nor the human earcan detect sounds below 20 Hz. The present embodiments successfullyprovide a solution to this problem by monitoring low frequencies whichrelate to the mechanics of ventilation. It is expected that suchmonitoring is more sensitive to changes in ventilation than auscultationperformed by the physician.

Another advantageous feature of the present embodiments is the abilityto adapt the analysis to the subject baseline conditions, both forhealthy subjects and for subject with lung disorders. For example, whena healthy subject is intubated, the baseline conditions can correspondto normal ventilation conditions. Conversely, a particular patient(e.g., a patient intubated after lung or heart operation), can alreadyhave pneumonia in one side, in this case the baseline conditions cancorrespond to one side pneumonia. The ability to adapt the analysis tosubject-specific baseline, allows the present embodiments to detectdeterioration in ventilation immediately (within a few seconds or less)once deviation from the baseline occurs.

Subject-specific baselines can be acquired for each of the sensinglocations, more preferably for all the sensing locations. Each suchsubject-specific baseline can be used in the monitoring by determiningwhether there are deviations from the baseline. This allows determiningthe symmetry of ventilation and the development of local disturbancewith asymmetric ventilation. Symmetric ventilation can be identifiedwhen the mechanical indices are identical on both chest sides. It isrecognized that the patches are not always places at symmetric spots,due to, e.g., changes in the posture, existence of anatomical constrains(due to chest drains, catheters, post operative wounds etc.).

Any asymmetry can be monitored by analyzing changes in signals both forindividual sensors and for the entire arrangement of sensors relative tothe baseline condition. Symmetric ventilation disturbance is identifiedwhen the deviation from a baseline associated with a one location issimilar to the deviation from a baseline associated with otherlocations, and asymmetric ventilation disturbance is identified whenthere are different deviations from different sensing locations. Thedeviations at the various sensing locations are preferably measuredrelative to the baseline at each sensing location. Such identificationsare advantageous because they can be used to determine the origin of theventilation disturbance, if occurs. Specifically, symmetric ventilationdisturbance typically occurs when the ventilation machine malfunctions(e.g., volume or pressure drop in the ventilation circuit), when theendotracheal tube is placed in the esophagus, when the endotracheal tubeis obstructed by any means, or when the endotracheal tube is dislodgedfrom the trachea. Asymmetric ventilation disturbance typically occurswhen the endotracheal tube is placed too low in the trachea (one lungventilation), when pneumothorax or atelectasis begins to develop, orwhen non gaseous objects (e.g., secretions, aspirated meconium orforeign body) are present in the big airways (bronchi). In variousexemplary embodiments of the invention the method, device and system ofthe present embodiments allow to detect at least one, more preferably atleast two, more preferably at least three, most preferably, but notobligatorily, any of the following ventilation abnormalities: air leakin the oropharynx, leak to the esophagus, development of threateningspace occupying lesion within the chest, as pneumothorax, lesions withinthe bronchial tree (obstruction, secretion, etc), shift in theendotracheal tube position within the mediastinum and changes in thevolume, flow or rate (velocity) of inflation in one or both lungs. Thesystem assesses lung function and characterizes changes in ventilationand in the distribution of ventilation by measuring signals fromdifferent location and from both side of the chest.

Referring now again to the drawings, FIGS. 2 a-b are schematicillustration of a system 20 for monitoring lung ventilation of asubject, according to various exemplary embodiments of the presentinvention. In its simplest configuration, system 20 comprises aplurality of motion sensors 22, which can be connected to a plurality ofsensing locations 24 on the chest 26 of a subject 28. In the exemplifiedand preferred configuration illustrated in FIG. 2 a, there are threesensing locations: a left upper location 24L at a left side of chest 26,a right location 24R at a right upper side of chest 26, and anepigastric location 24E at the epigastrium of subject 18, when thesubject lies on the back. It is to be understood that it is not intendedto limit the scope of the present invention to the specific sensinglocations illustrated in FIG. 2 a, and that many other configurationsare contemplated. Thus, the number of sensing locations can be one, twoor more. When there are two sensing locations, they are preferably, butnot obligatorily, left location 24L and right location 24R. When thereis a single sensing location, it can be a centered sensing location(e.g., between left 24L and right 24R locations), or it can be any ofthe three sensing locations illustrated in FIG. 2 a.

Motion sensors 22 sense the local motion of chest 26 at the respectivesensing locations 24. Sensors 22 can be any type of motion sensors,include, without limitation, displacement sensors, velocity sensors andacceleration sensors. Such sensors are known in the art and arecommercially available from many manufacturers and distributors, e.g.,Analog Devices, Nexense™ and others. In various exemplary embodiments ofthe invention the sensors are acceleration sensors also referred toherein as accelerometers.

System 20 further comprises a data processing system 30 which receivesand records the signals from motion sensors 22. System 30 is preferablysupplemented with a mathematical algorithm for analyzing the signalssuch as to determine status of the ventilation, e.g., by calculating oneor more indices characterizing the ventilation and comparing them to thesubject-specific baseline.

As used herein “data processing system” refers to any computerized unithaving a memory medium and being capable of receiving signals, recordingthe signals, at least momentarily, on the memory medium, and employing amathematical algorithm for analyzing the recorded signals. Arepresentative example of a data processing system is a personalcomputer or a portable computer supplemented by peripheral equipment,such as, but not limited to, amplifier, filters, con version means andthe like. A representative example of a data processing system suitablefor the present embodiment is provided hereinafter with reference toFIG. 3.

The mathematical algorithm can be embodied as a program of instructionsto be carried out by the data processing system. The program can bestored in the memory medium of the data processing system in formatreadable by the data processing system, or it can be stored in on aseparate computer readable medium (e.g., a CD ROM or a flash memorymedium) from which the program can be uploaded to the memory medium ofthe data processing system. The data processing system can also includea storage medium (e.g., a hard drive) in which the recorded signals, theprogram of instructions and/or the analysis results can be stored forfuture use. The analysis of the signals depends on the type of sensorsemployed. For example, when the sensors transmit displacement data, thedata processing system can calculates quantities which relate to volumechanges induced by the displacements of the sensing locations. When thesensors transmit velocity data, the data processing system firstintegrates the data to obtain displacement data and then calculates thedesired quantities. Alternatively, velocity data can be used withoutintegration to calculate selected, e.g., flow rate. When the sensorstransmit acceleration data, the data processing system integrates thedata twice to obtain displacement data and then calculates the desiredquantities. Alternatively, acceleration data can be used withoutintegration, or can be integrated once to obtain velocity data. The dataprocessing system can also calculate volumetric data, e.g., by modelingthe geometry of the chest and employing a numerical simulation.Alternatively, volumetric data can be calculated using a lookup table ora calibration curve. In various exemplary embodiments of the inventiondata processing system 30 calculates one or more ventilation indiceswhich characterize the ventilation status. Representative examples ofpreferred ventilation indices are provided in the Examples section thatfollows. The system also determines the transfer functions of therespiratory system at the various sensing locations. Such transferfunctions can be calculated, for example, by assuming that there are nochanges in the input (the output of the ventilator) and that all themeasurements at the different sensing locations relate to the same input(ventilation pressure or flow) is endotracheal tube. The system cancharacterize the cutoff frequency of the transfer function. It was foundby the present Inventors that the cutoff frequency is sensitive tochanges in the resistance to air flow or to changes in the lungcompliance (see, e.g., the resistors and the capacitors in thetheoretical model presented in FIG. 4 of the Examples section thatfollows). The changes in the transfer function can thus be used fordetecting changes in the lung mechanics and consequently in theventilation dynamics.

In various exemplary embodiments of the invention the signals are passedthrough low-pass, high-pass and/or band-pass filters prior to thecalculation of the ventilation status. The selection of filters dependson the type of calculation to be performed, as further detailed in theExamples section that follows. Broadly speaking, motion of the chestwall is characterized by the ventilation frequency which is typicallyfrom about 0.2 Hz to about 10 Hz (during high frequency ventilation).Consequently, the lung and chest dynamics are determined by relativelylow frequencies, typically below 30 Hz if one considers also severalharmonics. The acoustic sounds associated with the air flow within theendotracheal tube, the bronchial tree and the lung parenchyma arecharacterized by the frequency of breath sounds which is typically fromabout 20 Hz to about 2 kHz. Thus, for motion-based calculations,low-pass or low band-pass filters are employed, and for flow-basedcalculations, band-pass filters are employed. According to a preferredembodiment of the present invention the mathematical algorithm performsat least one analysis at frequencies which are below 20 Hz.

According to a preferred embodiment of the present invention system 20comprises an endotracheal tube device 32. Device 32 preferably comprisesan endotracheal tube 34 and an endotracheal position tracking element 36mounted on a distal end 38 of tube 34. Element 36 serves for monitoringthe position of distal end 38 within the trachea of the subject. Invarious exemplary embodiments of the invention element 36 is anelectromagnetic antenna (e.g., a coil) configured to detect anelectromagnetic field generated by a stand-alone transmitter 40, or byone more external position tracking elements 52 (not shown, see FIG. 2b). In response to the detected electromagnetic field, element 36preferably transmit tracking signals to data processing system 30.System 30 analyzes the tracking signals and determine the position ofelement 36, hence also of distal end 38. Element 36 can also be anyother passive or active position tracking element known in the art.Representative examples include, without limitation, position trackingelement operating on electric principles (impedance, capacitance),electromagnetic principles, acoustic principles (sonic or ultrasonic)and optical principles.

In various exemplary embodiments of the invention system 20 furthercomprises a display device 42 for displaying the ventilation status.Display device can also be a touch screen to facilitate easy operationof system 20. Preferably, system 20 further comprises an alert device 44which communicates with data processing system 30 and which generates asensible alert when appropriately signaled by system 30. System 30signals device 44 according to a predetermined criterion or a set ofcriteria. Preferably, system 30 preferably signals device 44 to generatealert when a ventilation abnormality occurs. In various exemplaryembodiments of the invention criteria for alerting is based on the valueor values of the ventilating index or indices calculated by system 30.Additionally, device 44 can operate as a “reminder” for the medicalstaff to perform various operations, such as reposition of the subject,replacement of tube device 32 and the like. Preferably, device 44generates different types of alerts for different situations. Thus, whenasymmetric ventilation is detected, device 44 generates one type ofalert, when a reduced air pressure is detected device 44 generatesanother type of alert, and so on.

According to a preferred embodiment of the present invention system 20further comprises a communication unit 46 for transmitting informationfrom system 20 to a remote location, which may be, for example, anursing control center in a medical or healthcare institution. Data tobe transmitted by unit 46 is preferably provided by system 30 which canalso control the transmission. The information transmitted by unit 46 ispreferably data pertaining to the ventilation status. For example, unit46 can transmit the value or values of the ventilating index or indicescalculated by system 30. The remote location may also be a physicianscenter (or place of residence) so that as to allow valuable informationto be transmitted to a physician without delay. Hence, the communicationunit is preferably connected to a telemetry apparatus or telemedicineapparatus.

FIG. 2 b schematically illustrates a patch 50 which preferablyencapsulates a motion sensor 22 of system 20. System 20 preferablycomprises a plurality of such patches, each encapsulating one motionsensor and optionally other elements as further detailed hereinbelow.Patch 50 is preferably of the attachable form to facilitate theanchoring of sensors 22 to chest 26. Thus, each patch is attached to oneof the sensing locations (e.g., locations 24L, 24R and 24E). Patch 50can also encapsulate an external position tracking element 52 which,together with endotracheal position tracking element 36 allows thedetermination of the position of distal end 38 of tube 34. The type ofelement 52 depends on the type of element 36. Specifically, element 36and elements 52 have receiver-transmitter relations. Thus, when element36 receives an electromagnetic field, element 52 is selected togenerates the electromagnetic field, and when element 36 generates theelectromagnetic field, element 52 is selected to detect theelectromagnetic field and to transmit tracking signal in response to theelectromagnetic field. In the latter embodiment the tracking signal istransmitted via line 54 to data processing system 30 (not shown, seeFIG. 2 a), which analyzes the signal and determines the position of theendotracheal tube. Additionally or alternatively, an external source ofelectromagnetic field 40 (see FIG. 4 a) can be used to determine theposition of element 36. In this embodiment, elements 52 serve asreference points for the position tracking.

Patch 50 can also encapsulate an ECG electrode 56. This embodiment isparticularly useful when the dimensions of the subject's chest are smalland there is insufficient area to connect sensor 22 and ECG electrode 56using separated patches. ECG electrode 56 transmits ECG signals via anECG lead 58 which is connected to an ECG display device (not shown).Optionally and preferably, patch 50 encapsulates at least onearrangement of electrodes 60 which sense one or more electricalproperties (e.g., conductance, impedance) of the tissue contacting thepatch. Electrodes 60 transmit signals to system 30 which analyzes thesignals so as to monitor the connectivity between the patch and thetissue. When the electrical property deviates from a predeterminedthreshold range or a subject-specific baseline acquired, a detachment ofthe patch from the tissue is identified and data processing system 30can signal device 44 to generate an alert. FIG. 3 is a schematicillustration of data processing system 30, according to variousexemplary embodiments of the present invention. The inputs of the system30 arrive from the patches, the endotracheal position tracking elementand a keyboard.

The outputs of are the currents to the magnetic field transmitters, thetransmitters within the patches or the endotracheal tube, the monitorand the alarm.

System 30 preferably comprises amplifiers and filters for amplifying andfiltering of the signals from the sensors. The input signals typicallyinclude a superposition of high amplitude and low frequency signals thatrelates to the chest wall motion and low amplitude and high frequencysignals that relate to the breath sounds. The low frequency signals areat the first harmonics of the ventilation frequency. The frequency ofnormal ventilation is about 12 per minute or 0.2 Hz, however,high-frequency ventilation consists of 600 cycles per minute or 10 Hz.This low frequency range relate to the motion of the chest wall. Thehigh frequency signals, from about 20 Hz to about 2 kHz, relate to thebreath sound and originate from the airflow within the bronchial tree.

The amplifiers and filters separate signals indicative of chest walldisplacement from the signals indicative of breath sounds. The chestwall displacement is thus evaluated using the low frequency signals,after amplification and passing though a low-pass filter with a cutofffrequency of about 30 Hz. To detect the breath sound, the signals arefurther amplified after passing through a bandpass filter. The band passattenuates the high amplitude signal at the ventilation frequency inorder not to bring the amplifiers to saturation. Suitable band-passfilters for the present embodiments are characterized by a low frequencycutoff of about 30 Hz and high cutoff frequency of about 2000 Hz.

Data processing system 30 preferably comprises an analog to digitalconverter that allows the data acquisition for further analysis andprocessing. System 30 further comprises a memory or digital storagemedium in which history is stored for display and analysis. The memoryor digital storage medium can store the compressed acquired data and thecalculated ventilation status, typically the ventilation indices, and/orendotracheal tube positions. The amount of data collected during 24hours from 10 channels at a sampling rate of 4 kHz adds to about 27 Gb.The ventilation indices are preferably evaluated at real time (e.g.,calculation time of 0.1 seconds or less) and sampled at a sampling rateof about 0.2 to 0.033 Hz.

The system preferably reevaluates the status every 5 to 30 seconds. Analert is preferably generated whenever the deterioration persists duringa time interval selected sufficiently short so as not to cause hazard tothe subject and sufficiently long so as to reduce the rate of falsealarms. Typical such time interval is about 30 seconds. The samplingfrequency of the calculated indices is preferably lower than theventilation frequency. For regular (CMV) ventilation the typicalsampling frequency is below about 0.2 Hz. For high frequency ventilationthere is no clinical need for sampling the indices at higher samplingrate.

Thus, the processed data of a 24 hours history adds to about 2 Mb orless. Memory or digital storage medium can also store the alarm history.History of more than 24 hours is also contemplated. For example, a 2months history requires storage volume of about 120 Mb or less. The dataprocessing system also comprises a Digital Signal Processing (DSP) unit,which includes programs of instructions for continuous analysis of thedata in the time and frequency domain, quantification of the ventilationindices, evaluation and identification of deterioration compared to thebaseline and the previous history and simple definition of theappropriate alarms. In various exemplary embodiments of the inventionsystem 30 comprises a control and timing module (denoted as “Clock” inFIG. 3), which schedules the transmitters (within the patches,endotracheal tube or the external source) and the digital sampling unit.

Optionally and preferably data processing system 30 comprises a userinterface (e.g., a display and a keyboard, a touch screen) which allowsthe operator to change the parameters of system 20. Representativeexamples of parameters which are controllable by the operator, include,without limitation, definition of the reference baseline to be used forcontinuous evaluation, selection of the operative sensors, selection ofthe ventilating indices, selection of accepted variability range andsubject identification. It is expected that during the life of thispatent many relevant sensors will be developed and the scope of the termmotion sensor is intended to include all such new technologies a priori.

Additional objects, advantages and novel features of the presentinvention will become apparent to one ordinarily skilled in the art uponexamination of the following examples, which are not intended to belimiting. Additionally, each of the various embodiments and aspects ofthe present invention as delineated hereinabove and as claimed in theclaims section below finds experimental support in the followingexamples.

EXAMPLES

Reference is now made to the following examples, which together with theabove descriptions illustrate the invention in a non limiting fashion,

Example 1 Ventilation Indices

Following is a list of ventilation indices which can be used tocharacterize the ventilation status, according to various exemplaryembodiments of the present invention. Each of the following ventilationindices is preferably calculated as a function of time and for eachsensing location. An averaging procedure can also be employed eitherover a predetermined period of time and/or over two or more sensinglocations. Additionally, an interpolation procedure can be employed soas to obtain spatial distribution of the ventilation index. Thus, eachof the following ventilation indices can be a function of both time andspace, a function of time, a function of space or a number.

Tidal Motion Index (TMD

The TMI is preferably defined to describe the local peak-to-peakamplitude changes of the chest wall displacement during ventilation. TheTMI can be calculated by subtracting the lowest amplitude of the chestwall from the highest amplitude of the chest wall over a single cycle ofventilation. The TMI is preferably evaluated after passing the signalsthrough an appropriate low-pass or band-pass filter.

Preferably, a low-pass filter is employed. The filter is characterizedby an upper frequency cutoff of about 30 Hz, more preferably about 20Hz, more preferably about 10 Hz, even more preferably about 5 Hz.Alternatively, a band-pass filter characterized by a low frequencycutoff of about 0.1 Hz and the above high frequency cutoff can beemployed.

Maximal Inflation Rate (MIIO

The MIR index is defined as the maximal rate of the inspiratory phaseand can be calculated by detecting the maximal rate at which the chestwall expands. The MIR index is preferably evaluated after passing thesignals through an appropriate low-pass or band-pass filter, asexplained above. The MIR index is sensitive to obstructions orresistance to flow in the large airways.

Maximal Expiratory Rate (MER) The MER index is defined as the maximalrate of the expiratory phase and can be calculated by detecting themaximal rate at which the chest wall recoils. The MER index ispreferably evaluated after passing the signals through an appropriatelow-pass or band-pass filter, as explained above. The MER index issensitive to obstructions or resistance to flow in the small airwaysystems.

Left to Right Motion Index (L2RM)

The L2RM index is defined as the ratio between the amplitudes of motiondetected at the left sensing location and the right sensing location.The L2RM preferably calculated from the total peak to peak motionamplitudes of the right and left sensing locations, respectively. TheL2RM index is preferably evaluated after passing the signals through anappropriate low-pass or band-pass filter, as explained above. It wasfound by the present Inventors that the L2RM index is sensitive to onelung ventilation and the development of pneumothorax or atelectasis. Anyasymmetry of ventilation (e.g., obstruction of some branch of mainbronchi) can be detected by the L2RM index. It was found by theInventors of the present invention that the L2RM index is sensitive toasymmetric ventilation, in particular in cases of pneumothorax, one lungventilation, partial obstruction due to secretion in one lung etc.Representative example of such sensitivity is FIGS. 8 (one lungventilation) and 10 (Pneumothorax).

Right to Left Flow Index (R2LF)

The R2LF describes the ratio between the flow into the right lung andthe flow into the left lung. The magnitude of the flow is preferablydetermined from the magnitude of the high frequency signals transmittedfrom the respective sensing locations. The high frequency signals relateto the breath sound and originate from the airflow in the bronchial treeof each side. The magnitude of the flows can be evaluated, for example,from the root-mean square values of the recorded signals, after passingthrough an appropriate filter. Preferably, a band-pass filter isemployed.

The filter is characterized by a low frequency cutoff of about 30 Hz anda high frequency cutoff of about 2000 Hz. Alternatively, a high passfilter characterized by frequency cutoff of about 30 Hz can be employed.

Epigastric Leak Motion (ELM)

The ELM index is preferably defined as the ratio of the tidal motionamplitude as determined from signals received from the epigastricsensing location to the tidal motion amplitude as determined fromsignals received from averaging the signals measured at the left andright sensing locations. The tidal motion is evaluated from the lowfrequency band of the recorded signals. The ELM index is preferablyevaluated after by passing the signals through an appropriate low-passor band-pass filter, as explained for the TMI hereinabove.

Epigastric Leak Flow (EFF) The EFF index is preferably defined as theratio of the flow as determined from signals received from theepigastric sensing location to the flow as determined from averaging thesignals received from the left and right sensing locations. The flow isevaluated after passing the signals through an appropriate high-pass orbandpass filter, as explained for the R2LF index hereinabove.

Transfer Function Cutoff Frequency (f_(r))

The f_(c) index is preferably defined as the cutoff frequency of thetransfer function between the pressure or flow input and the chest wallmotion. The cutoff frequency if proportional to the product of theresistance to flow and the chest compliance. Any change in the lungcompliance or volume (lung capacity) or development of obstruction toflow (resistance) affects the f_(c) index. The f_(c) index decreaseswith the increase in the resistance to flow or the increase in thecompliance, and vise versa. The f_(c) index can be calculated byperforming spectrum analysis of the signals at the frequency domain.

Endotracheal Tube Relative Position (ETRP)

The ETRP index is preferably defined in terms of the distance of theendotracheal tube from one or more reference points, which can be, forexample, one

or more of the sensing locations or another location at which a positiontracking element is positioned. The value of the ETRP index can beprovided, e.g., in millimeters, relative a single reference point or aplurality of reference points. Thus, the ETRP index can be a vector oftwo or more entries.

Shift in the Endotracheal Tip (ET-s)

The ET-s index is defended as the difference between values of the ETRPindex obtained at different times. The ET-s index is used to detectsmall changes in the position of distal end of the endotracheal tube inthe trachea. The ET-s can be used to detect either displacement of thetube (up or down) or shift in the mediastinum, due to pneumothorax andthe development of other space occupying lesions,

Example 2 Ventilated Lung Model

A simplified scheme of a ventilated lung is illustrated in FIG. 4 a.

Vin represents the mechanical ventilation machine generating a pulsatilepressure or flow.

R_T represents the impedance to flow through the endotracheal tube. Thethin tubes (3-4 millimeters in diameter for neonates) impose highresistance, especially at high velocity.

R_L represents the air leak through the upper air ways (mouth and nose),especially when the tip of the tube in place in the oropharynx. It isdescribed by a variable resistor. When the tube is displaced to theoropharynx this resistance decreases to simulate the large leak. Whenthe tube is placed in the appropriate position and a balloon is inflatedto fix the position of the tube and to prevent leak this resistanceapproach infinity.

R_SS, R_SP and C_S represent the components of the impedance to flowinto the stomach. This impedance include a serial resistive element(flow in the esophagus) R_SS, and additional resistive element R_SP inparallel with a capacitive element C_S that describes the compliance ofthe stomach to inflation. This impedance is especially prominent whenthe tube is within the esophagus. In such situation, R_SS decreases.

R_UAW and C_UAW represent the impedance (resistance and compliance,respectively) to flow in the upper bronchial airways tree. Thecompliance also reflects the dead space inside the bronchial tree. It isassumed that the compliance of the endotracheal tube is negligible(stiff relative to the bronchial tree). R_LL and C_LL represent theimpedance to flow (resistance and capacitance, respectively) in thesmall airways of the left lung. RJRL and C_RL represent the impedance toflow (resistance and capacitance, respectively) in the small airways ofthe right lung. The capacitance also describes the volume of theventilated alveoli in the respective lung. RJP, C_P and DJP representair flow into volume occupying lesion, where there isventilation-perfusion mismatch, as in pneumothorax. DJP is a diode thatallows only one directional flow, and C_P allows description of thevolume of the pneumothorax that reduces the apparent chest volumeavailable for lung expansion.

C_LW and C_RW represent the compliance of the left and right chest wall,respectively.

Ruled represent the resistance to air flow within the pleural space fromthe right to the left side, within the mediastinum (note that thepleural space is very small and is usually filled with serous fluid andthe heart is positioned between the left and right lungs). FIG. 4 ashows a spectral analysis of high frequency ventilation, demonstratingthat the ventilated lung behaves as a low-pass filter due to theresistor-capacitor combination.

Example 3 Experimental Trial

Following is a description of an experiment in which chest wall motionin a ventilated rabbit model was monitored according to preferredembodiments of the present invention using a prototype system.

Methods

The experiments were performed according to the guidelines approved bythe Institutional Animal Experimental Ethics Committee of theTechnion-Israeli Institute of Technology. The experimental study wascarried in 7 adult male rabbits, 2.3±0.2 Kg of weight. The experimentalsubjects were anesthetized by intramuscular injection of Xylazine (10mg/kg), Ketamine (90 mg/kg) and Fentanyl (0.2-0.6 ml/kg) with repeateddoses during the experiments. Endotracheal intubation was performed bydirect laryngoscopy and a 3 mm diameter endotracheal tube (ETT—PortexLtd., UK) was introduced into the trachea.

Mechanical ventilation was initiated and ventilatory parameters werestandardized in order to keep the blood PH, PO₂, and PCO₂ withinphysiological limits. ECG, pulse oxymetry and arterial blood pressurewere monitored (M-NE12STPR module, Datex Ohmeda Inc, Wisconsin, USA).Mechanical ventilation was provided using an SLE 2000 mechanicalventilator (SLE, Surrey, UK). Continuous—conventional—MandatoryVentilation (CMV) initial ventilatory setup: Inspiratory:Expiratoryratio (1:E ratio): 1:2.8, Peak Inspiratory Pressure (PIP) 21 cm H₂O,FiO₂ 0.21, ventilation rate of 30 per minute (0.5 Hz). Ventilatorparameters were individually adjusted according to pulse oxymetrymonitoring and blood gas analysis. Several mechanical perturbations werestudied: (i) decrease in peak inspiratory pressure by 11%, 20%, 33%, and66% from baseline; (ii) asymmetric (right lung) ventilation; (iii)formation of pneumothorax; and (iv) ventilation trough the esophagus.Selected events were repeated 3 to 4 times each. The decrease in peakinspiratory pressure event was achieved by controlling the ventilationmachine (see the experimental setup in FIG. 5). The asymmetricventilation event was achieved by advancing the endotracheal tube intothe right main bronchus so as to perform selective right lungventilation. The pneumothorax event was achieved by injecting air intothe pleural space. A thin (10Fr) chest tube was inserted into thepleural space between ribs 6 and 7. The insertion site was sealed by asurgical stitch and biological glue. Air was injected using a syringeinto the right pleural space, through the drain tube, or in sequentialsteps (20 ml at each step), thus forming pneumothorax of the righthemithorax. The steps were repeated until a decrease of oxygenation inpulse oxymetry was observed. A total air volume of up to 120 ml (sixsteps) was injected.

The Experimental setup is illustrated in FIG. 5. Right (R), left (L) andepigastric (EP) motion sensors were attached to the chest of theanesthetized and ventilated rabbits. Electronic stethoscopes wereattached to both sides of the chest. Sensors data were amplified,collected through high-pass (HP) and low-pass (LP) filters, and recordedand processed in a data processor. Heart rate (HR), blood pressure (BP)₅pulse oxymetry (SpO₂), end-tidal CO₂ (ETCO₂) and pressure at theproximal port of the endotracheal tube (TP) were also recorded.

The motion sensors were ADXL320 accelerometers purchased from AnalogDevices. All other sensors were purchased from Datex InstrumentationCorp. The electronic stethoscopes (Labtron Electromax, Hauppauge, N.Y.,USA) served for comparison of with conventional auscultation performedby experienced personnel.

The high and low pass filter served for separating the signals from theaccelerometers into two frequency ranges: 1-100 Hz and above 100 Hz.Each frequency range was amplified separately (BMA-931 Bioamplifier, CWEInc., Ardmore, US). The data was analyzed in the time and frequencydomain utilizing dedicated signal processing software. The highfrequency signals relate to the flow inside the bronchial tree while thelow frequency signals directly relate to the chest wall motion. Thetransfer functions of the chest wall at the various locations werecharacterized. Conventional parameters, including heart rate (HR), whichwas determined from the ECG, mean arterial blood pressure (BP),end-tidal CO₂ (ETCO₂), and pulse oxymetry (SpO₂) were continuouslyrecorded simultaneously with the output signals from the motion sensors.The data was acquired and displayed utilizing analogue-to-digital card(PCI-MIO-16E-4, National Instruments, Austin, Tex., USA) and Labviewsoftware (LabVIEW™, National Instruments, Austin, Tex., USA). Pressureat the proximal port of the endotracheal tube (TP) was continuouslymeasured and recorded.

The mechanical signals and all of the other parameters were recorded foreach event. Each record lasted 3-5 minutes and included about 1 min ofbaseline. The event start point was marked as the time period of theinduced perturbation, and the end of event was marked as well as thetime until all hemodynamic parameters and oxygen saturation were back tobaseline. Off-line digital signal processing was performed using signalprocessing software (Matlab™, MathWorks, Natick, Mass., USA). The timedelay of the diagnosis of each event by the different monitoringparameters was measured relative to the start-point of the perturbation.Limits of significance for each parameter change from baseline wereconsidered as a 5% deviation from baseline.

Based on the signals obtained from the motion sensors, mechanicalindices determination was performed by the analysis of the low frequencysignals, relating to the mechanics of the chest wall motion.

Acceleration and decelerations raw signals were translated to relativevolume changes measurements, expressing the measured indices as globaland local indices, based on the integrated measurements from allsensors. The following indices were measured: Tidal Motion index (TMI),defined as the total peak-to-peak amplitude of the chest wall motion;Maximal Inflation rate (MIR), defined as the maximal flow during theinspiratory phase; and Maximal Expiratory Rate (MER), defined as themaximal flow during the expiratory phase. The indices were used toassess ventilation symmetry, comparing the right to the left and to theepigastric sensors. Relative volume changes of individual sensors werealso assessed.

Results FIGS. 6 a, 6 b and 6 c show examples of the response toreductions in the peak inspiratory pressure by 66% (from 18 to 6 CmH₂O)33% (from 18 to 12 cmH₂O) and 11% (from 18 to 16 CmH₂O), respectively.As shown, with a 11% reduction in peak inspiratory pressure only the TMIdefined and measured according to various exemplary embodiments of thepresent invention dropped immediately showing a change from baseline.Conversely, no significant changes were observed in the traditionalparameters as heart rate (HR), pulse oxymetry (SpO₂), blood pressure(BP), or end-tidal CO₂ (ETCO₂). The more severe perturbations (FIGS. 6a-b) of 66% and 33% showed appropriate responses in most parameters andan early response of the motion sensors. In FIGS. 6 a-c, marks are themeasured and calculated indices, as defined at the end of each cycle,while the continuous lines show the mean values of the measurements.

FIGS. 7 a-b show the time elapsed (mean time±standard error time) fromthe initial change in the endotracheal tube pressure until a 66% (FIG. 7a) and 33% (FIG. 7 b) decrease in the ventilation pressure was detected.Shown in FIGS. 7 a-b are the response delay in seconds for the TMI, MIRand MER parameters of the present embodiments, and the traditional endtidal CO₂ (ETPCO₂), heart rate (HR), blood pressure (BP) and pulseoxymetry (SpO₂) parameters. As demonstrated, the parameters of thepresent embodiments allowed almost immediate detection of the relativevolume change in ventilation, whereas the traditional parameters showedsignificant delays.

FIGS. 7 c-d show the time elapsed until a 20% (FIG. 7 c) and 11% (FIG. 7d) decrease in the ventilation pressure was detected. As shown in FIGS.7 c-d the response delay for the TMI, MIR and MER parameters of thepresent embodiments within one to three breathing cycles, i.e. withinless than 6 sec (the ventilation rate was 30 per minute) for 20%decrease, and within one to two breathing cycles, i.e. within less than4 seconds for 11% decrease. The traditional parameters showed noresponse. The experiments were extended up to 5 minutes in order to waitfor a possible response of the traditional parameters.

FIG. 8 shows examples of response to right lung ventilation. As shown, asignificant drop from baseline was observed in the TMI defined andmeasured according to various exemplary embodiments of the presentinvention. Significant change was also observed in the L2RM index thatdescribes the ventilation of the left lung relative to the right lung.The indices TMI and L2RM showed that while there is decrease in thetotal decrease in the ventilation there is relatively over inflation ofthe left lung compare to the right lung. FIG. 8 demonstrates theadvantage of the present embodiments over the conventional BP, SpO₂ andETCO₂. The present embodiments provide additional important informationthat can facilitate the identification of precise diagnoses.

In FIG. 8, marks are the measured and calculated indices, as defined atthe end of each cycle (every 2 seconds), while the continuous lines showthe mean values of the measurements. FIGS. 9 a-b show the time elapsed(mean+standard error of the mean) until changes induced by the placementof the endotracheal tube into the right main bronchus (FIG. 9 a) and theesophagus (FIG. 9 b) were observed. Both procedures induced significantchanges in heart rate, arterial blood pressure, pulse oxymetry and endtidal CO2 with high variability and some delay when compared to theparameters TMI, MIR and MER of the present embodiments. The changes inair entry to the lungs were corroborated by auscultation of experiencedpersonnel.

FIG. 10 presents the sensitivity of the system of the presentembodiments to a gradually induced pneumothorax. Shown in FIG. 10 areraw data as a function of time, that were acquired from the pulseoxymetry sensor (top), the pressure sensor at the proximal port of theendotracheal tube (TP, second row) and form the right accelerometer andthe left accelerometer (bottom). The arrows in FIG. 10 indicate thesteps of 20 ml injection of air into the right pleural space. As shown,an immediate reduction in the right accelerometer signal was noticedfrom the first injection, indicating reduction of right lungventilation. After 23 minutes and only after the injection of 80 ml ofair into the pleural space, the signal from the left accelerometerdecreased, probably due to the induced mediastinal shift. Note that thevolume of the rabbit chest is of about 160-200 ml, A comparison betweenthe signals received from the right and left accelerometers revealed aconspicuous development of asymmetric ventilation. Conversely, the pulseoxymetry signal did not show any decrease during about 23 minutes. Onlyafter the fifth injection of a total amount of 100 ml a minor andinsignificant decrease was observed in the pulse oxymetry signal. Notealso that no significant change was observed in the endotracheal tube(Tubus) pressure (TP).

It is noted that the volume of the rabbit's chest is about 160-200 ml.Thus, the technique of the present embodiments allows early detection ofsmall pneumothorax (20 ml which is about 10-12% of the chest's volume),whereas traditional techniques fail to present specific detection evenwhen the size of the pneumothorax is as large as 120 ml (about 60-75% ofthe chest's volume). Also shown in FIG. 10 are instants at which theinjected air was extracted. As shown, the signals from theaccelerometers returned to its baseline immediately after extraction.

Example 4 Exemplary Ventilation Procedure

FIG. 11 is a flowchart diagram exemplifying a procedure for utilizingvarious embodiments of the present invention.

The exemplary ventilation procedure begins at step 110.

In step 111, the sensor and transmitters are attachment to the body ofthe patient. In steps 112, 113 and 114, various signals are recorded. Instep 112 the signals relate to lung inflation (motion signals), in step113 the signal relate to the position of the endotracheal tube (trackingsignals), and in step 114 the signals are surface electrocardiogramsignals. Steps 112, 113 and 114 are preferably executed in parallel.

Steps 115 and 116 are analysis steps. In step 115 the motion signals areanalyzed to determine the characteristics indices of the ventilation,and in step 116 the tracking signals are analyzed to determine theposition of the endotracheal tube within the trachea.

Step 117 represents the attachment quality control. In this step anelectrical property of the tissue contacting the patch is measured tomonitor the connectivity between the patch and the tissue. In step 118of the exemplary ventilation procedure, the algorithm analyzes all thedata and presents the baseline indices to the attending physician andmedical staff. In step 119, the system receives from the user, two typesof inputs: (i) an approval from the attending medical staff to start themonitoring based on the measurements that serve as the baseline; and(ii) the selected set of alarms (threshold for the allowed variations).The physician can examine the patient, listen to the chest and verifythat the baseline corresponds to proper ventilation. Once suchverification is achieved, the allowed variations from the baseline areset and the system enters an automatic monitoring mode.

During monitoring, steps 112-116 are repeated, and the algorithmcontinues to step 120 in which the data acquired during the analyses arearchived by recording the indices into the memory.

In step 121 the recent measurements and the trend in the recent recordedhistory are compared to the baseline. In decision step 122 the algorithmchecks whether or not there are significant changes (based on the alarmsetup of step 119). If there are significant changes, the algorithmproceeds to step 124 in which the changes are defined in terms oflocation and nature. From step 124 the algorithm continues to step 125in which an alarm is generated. The medical staff can then attend to theventilation problem identified in step 124 and resolve it. From step 125the algorithm continues to description step 123. If in decision step 122the algorithm finds that there are no significant changes, the algorithmproceeds directly from decision step 122 to decision step 123. Fromdecision step 123, the algorithm either proceeds to ending step 126 inwhich case the exemplary ventilation procedure ends, or loops back tosteps 112, 113 and 114 in which case the ventilation monitoringcontinues.

It is appreciated that certain features of the invention, which are, forclarity, described in the context of separate embodiments, may also beprovided in combination in a single embodiment. Conversely, variousfeatures of the invention, which are, for brevity, described in thecontext of a single embodiment, may also be provided separately or inany suitable subcombination.

Although the invention has been described in conjunction with specificembodiments thereof, it is evident that many alternatives, modificationsand variations will be apparent to those skilled in the art.Accordingly, it is intended to embrace all such alternatives,modifications and variations that fall within the spirit and broad scopeof the appended claims. All publications, patents and patentapplications mentioned in this specification are herein incorporated intheir entirety by reference into the specification, to the same extentas if each individual publication, patent or patent application wasspecifically and individually indicated to be incorporated herein byreference. In addition, citation or identification of any reference inthis application shall not be construed as an admission that suchreference is available as prior art to the present invention.

The invention claimed is:
 1. A method comprising: receiving signals froma plurality of sensing locations on a chest of a subject, at least aportion of said signals being indicative of a local motion of said chestat a respective sensing location, and continuously monitoringventilation and heart function using data of the local motion of thechest; and analyzing said signals such as to determine a status of theventilation, thereby monitoring the lung ventilation of the subject,wherein analyzing comprises calculating at least one ventilation indexcharacterizing the status of said ventilation for at least one sensinglocation, wherein said at least one ventilation index is calculated as afunction of time and for each sensing location, wherein said at leastone ventilation index comprises acceleration or deceleration.
 2. Themethod of claim 1, wherein said at least one ventilation index comprisesa tidal displacement index that represents a tidal peak-to-peakdisplacement of each sensor.
 3. The method of claim 1, wherein said atleast one ventilation index comprises a maximal inflation rate index. 4.The method of claim 1, wherein said at least one ventilation indexcomprises a maximal expiratory rate index.
 5. The method of claim 1,wherein said at least one ventilation index comprises maximalacceleration or deceleration.
 6. The method of claim 1, wherein said atleast one ventilation index comprises angular acceleration.
 7. Themethod of claim 1, wherein said at least one ventilation index comprisesangular velocity.
 8. The method of claim 1, wherein said at least oneventilation index comprises spectral characteristics of the signals in afrequency domain.
 9. The method of claim 1, wherein said at least oneventilation index comprises a right to left motion index.